Career Update: Part 1

So I started out in Cardiac Telemetry as a new grad. I knew right out of school that I wanted to have  Telemetry as a foundation for my practice. If you are starting out as a new grad in the US, Tele is a great start. From Tele it is much easier to navigate into specialty areas than moving from Med-Surg. After about 18 months I was fatigued with my job. I worked on the biggest unit in the hospital which was split into regular Tele, Med-Tele, VIP unit, and observation unit; as well as being floated to MICU, CVSD, Maternity, Med-surg and the new sister hospital which had opened a good 20 min drive from the main campus. I had started working on days as a new grad as I thrive under pressure. I learned so much in the first 6 months and definitely found my groove, understanding my patients, documentation and the docs. I found that I really enjoyed working the observation unit as it was high turn over, fast paced, and a bit of a mystery of what the ER was bringing up. One time I had a pt come up dx: Chest Pain. I gave her morphine, did an EKG, put her on O2, call the doc – she was immediately sent to the cath lab. This pt should have been a cardiac alert, turned out that she had 100% occlusion in the Circumflex – she was dying. I loved that I was on the cusp of something, it was fast, it was more challenging than the other units and I liked it. After about 14 months on days, I switched to night shift. Our night shift staff was thin, a lot had left and they were struggling, and to be honest, I needed the pay increase. So I did nights for the last 5 months of my job and started looking for other opportunities.

I landed a job at another hospital, again it was a non-profit hospital, but in an affluent area. I was working in CV-Step Down, sister floor to CVICU post-CABG/TAVR pts mainly. I was thrilled that I was moving deeper into the cardiac specialty, this is what I wanted. After 3 months in my new job I wasn’t happy. I was working nights, the staff were burned out and it showed. I found that the acuity of my patients weren’t all that different from my prior job. Post-open heart really only meant, possible Afib – start Cardizem or Amiodarone drip, chest tubes – usually 2-4, Dermabond midline chest incision and leg donor site, and lastly a foley. There was nothing really interesting about it. The fun happened in the OR, ICU and then during the day when the chest tubes were pulled, I missed out on all of that and just ended up changing the chest tube dressing and drawing blood from the central line.

I started to feel depressed; I started dreading going to work. I wondered if I was looking for something better that didn’t exist. I thought nursing was this great expanse of possibilities, but here I was feeling crappy after changing jobs from a crappy position to another one. I considered if I just wasn’t made for nursing. I’ll be honest, I never planned on being a nurse, I didn’t grow up dressing up as a nurse and putting a stethoscope to my teddy bear – that wasn’t me. Life brought me to nursing, and my ability to take on a challenge, think critically, enjoy interacting with people, had made this a good choice for me, but now I was here in this place where I was unhappy and couldn’t quite figure out how to fix it. So I did what I thought I should do and start looking for another job. Now I was looking for a higher level: ER, ICU, ICU specialities.

Ironically I reapplied for some of the jobs I had applied for when leaving my first job. I really just felt like I had nothing to lose. I did get a call back for an ER job at a Level II Trauma hospital right on the highway. It is one hospital within a large hospital system, which means there are a lot of jobs available without actually quitting and having to learn a whole new system over again. So, I booked the interview and figured I’d wing it, at the end of the day, I still had a job, even if I didn’t get a new one, the bills would still get paid haha!

Stay Tuned for what happens next…!

 

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Top 10 highest paying nursing specialties – Repost

Top 10 highest paying nursing specialties (via http://scrubsmag.com/)

After you finish nursing school, or if you’re considering going back for more training, choosing the right nursing specialty becomes your chief focus. With so many specialties to choose from, many prospective nurses find it difficult to just pick…

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A New Way To Vent? Twitter Anons…

Everyone who’s anyone know about the new technological issues we are facing with workplace professionalism and social media. The debate over what employers should be able to judge you on when you are “off the clock”, and what is your personal and private life is a hot topic. So is there are growing movement to counter this on twitter? I think so! Many people see social media as a way to communicate their thoughts or feelings with others who they may or may not know. They find commonalities in agreements and disagreements, but somehow, this new outlet of self expression is now being censored because people are afraid of what their employers may see, think or act upon. So in stifling this self expression has caused an emergence of those who call themselves “anons”. They are individuals in the medical and healthcare field who create accounts under a medical theme and feel free to talk about anything they want without threat of their words biting them in the ass later.

There is now a whole community of Anons on twitter: Doctors, RNs, Nursing Students. Much of what is posted is nursing advice, sarcastic jokes, banter, vague but hilarious stories. I follow several Anons and enjoying catching up on my tweets every morning in place of a newspaper – trust me the tweets are much more amusing.

So is this a good thing, or a bad thing? I am pro-anons. I feel that this is a great outlet of self-expression and a perfect answer to the employment bombardment on our private lives. Yes using social media is allowing your private life to be shared, but I don’t believe that your personal life has anything to do with your professional performance. Looking back into history we have had many great leaders who were struggled with demons in their personal lives, and yet, they got the job done.

Are you thinking about becoming an Anon, or following some? Search for names like Nursing Anon, Premed Student or Nightshift MD – there are so many. Follow one and see the similar options provided by Twitter, that is a helpful way to network the anon community. If you are becoming an Anon, think about you name, that is what people will be basing their decision to follow you off of.

So join the community, reclaim your self-expression and live without fear! Social media is a powerful and wonderful thing, lets share the knowledge and love around in the healthcare community!

Nursing Skills: NG Tubes!

NG tubes. Yes, they’re pretty gross. Anything going in or coming out of the nose is gross, have you seen the stuff that comes out when an NGT is put to suction? I’m talking rainbow secretions! All joking aside, if you think they are gross, just imagine how the patient feels. I put a NG tube in the other day and was struggling to get it around the sinuses, it isn’t a straight route y’know.

So advice for NG insertion:

• Explain EVERYTHING to the patient! Tell them it will be uncomfortable. Tell them you will be there for them. Tell them that it is crucial to swallow. Tell them you are going to try to do the procedure as quick as possible. REASSURANCE is key!
• Pre-medicate if necessary. This is controversial. My patient the other day got morphine sulfate IV before the procedure, this totally helped in chilling out her gag-reflex and made the process easier BUT, if your patient is prone to becoming sedated or unable to follow commands then lay off the meds – use your judgement.
• Measure correctly. Remember that it is nose to ear to xyphoid process – mark it with tape.
• Lube, lube and more lube! We need that tube to slide and it has a long way to go, so be liberal with that lube!
• Encourage your patient to sip water. The swallowing effect with assist you in moving the tube down the esophagus.
• Don’t give up in getting it down! There may be issues along the way so troubleshoot fast. If you cannot get it pass the sinuses, twist and manipulate the directing you are inserting the tube. Have the patient open their mouth to check for coiling in the back of the throat.
• Lastly, always check your placement. Use the piston to blow an air bubble in, listen at the xyphoid process with your stethoscope for the air bubble. Placement is also checked with a follow up CXR.

There are many reasons why an NG tube may be placed. There are reasons to suction, give meds, remove acid, or feeding – regardless they are not comfortable for the patient and careful consideration should be made for skin breakdown in the nares or insertion site.

Cardiac Tamponade

This has nothing to do with tampons in the heart ok! Just an FYI.

When blood or fluid accumulate in the sac which surrounds the heart it exerts pressure against the heart, making it harder for the heart to pump. As you can imagine, if the ventricles cannot fill fully or contract effectively then cardiac output decreases. Decrease cardiac output is not good news!

So how do you know if someone has this?

Well the symptoms are nothing unusual: chest pain, restlessness, quick shallow breathing, palpitations, pallor, tachycardia, weak peripheral pulses, pulsus paradoxical, distended neck veins, low BP… (do these all sound a little familiar? MI anyone?) Well causes of cardiac tamponade can be MI, Dissecting aortic aneurysm (thoracic), end-stage lung cancer, heart surgery, Pericarditis caused by bacterial or viral infections, or direct wounds to the heart.

How do we diagnose? Echocardiogram is the usual diagnostic tool, but MRI, CT, CXR or EKG can also highlight or confirm this.

Can you see the halo of fluid around the heart?

This is an emergency! The fluid must be drained to reduce damage to the myocardium and reestablish cardiac output.

Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac, the tissue that surrounds the heart. The patient will be hyperoxygenated, given fluids to maintain blood pressure. It is important to note that a pericardiocentesis may have to be repeated because cardiac tamponade can return. With fast treatment the outcome is usual good, without treatment death is immanent.

A pericardial draining tube may be placed during surgery to keep in place postop. The drainage will be measured every shift and documentation on the color, amount and consistency is very important! The tube will usually be removed slowly over the postop recovery weeks at the discretion of the cardiologist.

NCLEX Success: Remember your A-B-Cs!

Say it with me: AIRWAY, BREATHING, CIRCULATION!

If you have renewed CPR with AHA recently you’ll know that they have changed that to CAB from ABC, but for NCLEX you need to stick with the ABC.

So here comes that irritating priority question. You try to apply Maslow but all options are physiological, so there is nothing to eliminate. What do you do? You apply the ABCs.

Airway will always be the most important factor to take priority: anaphylaxis? Choking? So look for it, if it isn’t there, look for breathing, it could be simple like raising HOB to decrease dyspnea in a CHF pt – keep focused on the “B” until you can rule it out. If no luck at that point, move to circulation. Hemmorhage? Potential for bleed? Change in vitals (↑HR, ↓BP)?

Look at the big picture and apply all the ABCs and use them to lead you to the right answer! Priorities will always contain ABC/Maslow or combination! Use your question answering skills! 🙂

Nursing Skills: Reasons for Chest Tubes

So I thought I’d write about chest tubes this week because I had a patient with two chest tubes and was post removal of a pericardial tube also. Not only that, but a colleague had a young pt in his 20’s whose chest tube popped out on the same day! Needless to say I thought it would be a great topic to cover. I’ll break it into three postings

Firstly, chest tubes aren’t as scary as they appear: sure, they are stuck in someones chest but there are many different reasons for a chest tube so knowing a thorough background on your pt is very important.

The procedure for placing chest tubes is called a Thoracostomy.

Reasons for inserting a chest tube:

Pneumothorax: This is when air collects in the pleural space; can also be referred to as a “collapsed lung”. The air pressure in the pleural space does not allow the lung to reinflate.

Pneumothoraxes can occur after central line insertion, after chest surgery, after trauma to the chest, or after a traumatic airway intubation. It is very important to remember that if the air continues to collect in the chest, the pressure in that pocket can increase and push the whole mediastinum over to the other side – this is called a “tension pneumothorax”, and is  life-threatening.

 

 

 

 

 Hemothorax: This is is when blood fills/pools in the pleural space and reduces the area for lung expansion. This can happen due to trauma or surgery. There is a possibility of having a hemo-pneumothorax which means air and blood fill the cavity. Also there remains the risk for medialstinal shift “hemo-tension-thorax”, this would be an emergency.

 

 

 

 

 

Pleural Effusion: This is the accumulation of fluid in the pleural space. This can be caused by CHF, liver failure, kidney failure, peritoneal dialysis, pneumonia, lymphoma or breast cancer. Though most pleural effusions are caused by congestive heart failure, pneumonia, pulmonary embolism and malignancy.

 

 

 

 

 

 

 

 

 

 

 Empyema: This is when pus is the substance which fills the pleural space. This is clearly cause by infection, but the pressure of pus in the pleural space makes it difficult for pts to breathe freely, they will likely have fevers and chills, malaise and chest pain.

NCLEX Success: Maslow’s Hierarchy of Needs

Maslow is a great tool to narrowing down or answering NCLEX questions. Those pesky priority questions are the ones in which Maslow can lend a helping hand. Here is how you use the Maslow Strategy:

1. Look at the answer choices. Determine if the answer choices are both physiological and psychosocial, if they are – apply the Maslow strategy.
2. Now, eliminate all psychosocial answer choices.
3.  If the answer choice is physiological, don’t eliminate it. Maslow states that physiological needs must be met first. Although pain certainly has a physiological component, it is considered a psychosocial need on Nclex.

The New Grad Healthcare Dilemma – Employment

It is true that healthcare is a fantastic career direction. Guaranteed employment, flexibility, variety, self-fulfillment and the list can go on… BUT, as a new graduate still wet behind the ears soon finds out, getting your foot in the door is the biggest challenge you’ve faced yet. Now there are always exceptions to the rule, and those who have an “in” at a facility or family member to help etc; but for those of us who have no helping hand, we are greeted by the cold hard fact that all healthcare employers want EXPERIENCE.

So how can one gain experience without securing a job requiring experience? Hence, our dilemma.

Getting around this is a difficult task, and demoralizing for most. Though, I have found that the main aim in this challenge is for your personality to jump off the resume page and get yourself into an interview. Many things can change during an interview: a face to a name, an impression, professionalism, self-expression, presence etc. All of these things can expunge the need for “experience” if you can give the employer a presentation of your competence and comportment during an interview. You build faith in them, that “you got this!”

So why then do some sink and some swim? Well there are two points of failure in my eyes: 1. Getting the interview, 2. Failing the interview.

1. In order to secure an interview you have to be aggressive about it. Yes, that may mean a little stalking, hounding, whatever other creepy adjective you want to use. I advise if you are seeking employment at a hospital, bug the switchboard. Call and ask for the name of the nurse manager, nursing director, or other title for the area you desire. Once you have the name ask to get put through to their phone line (more often than not they will not pick up), if you get to speak to the person, make a good introduction. If you have to leave a voicemail, introduce yourself and state that you have recently put in an application at HR and would love to talk further about opportunities available in [whatever area you desire]. At the end thank them for their time, request that they get back to you at their earliest convenience and repeat your name and leave your number. A voicemail is almost better in this case because it allows the contact to save the message and look up your application later when they have time, rather than trying to write down your information whilst talking with you. Furthermore, Google the name of the contact you got from the switchboard, maybe an email address will pop up. If so email the address in a formal, professional manner, stating the same as in the voicemail, include a copy of your cover letter and resume (personalized to the individual).

2. Sealing the deal in the interview comes down to a couple of things: looking the part and saying what they want to hear. Depending on your career choice, make sure you have your information straight before sitting in front of a potential employer. For nurses, find out the motto and mission statement of the hospital. Go over some common interview questions prior to the interview; think about your weaknesses, strengths, stories which display these, where you see yourself in 5 years, and why you are a good fit for the hospital/facility. Remember this cannot come across as rehearsed, but that something will spring to mind when you are under pressure. Giving account of good customer service is always a positive thing, particularly because hospitals are relying on this element for reimbursement. Lastly the best price of advice I can give for an interview – remain true to who you are. Lying increases pressure and will likely be noticeable, if there is an awkward question, it would be better to avoid a controversial topic rather than lying. I know that my honesty, enabled me to come across as natural as possible when interviewing, and it definitely worked in my favor.

So let the battle commence, don’t ever give up or lack self-confidence because you cannot find a job, it is simply the nature of the beast, and no one can prepare you for it. If you are currently in clinicals, I advise you start cultivating relationships with the nursing managers and other staff there, to make a pathway for a job after graduation – it will cut out a lot of hard work and crap in the long run.

Now when you look at job postings and they state a requirement of 1 year, screw them! Send in that app anyway! Why? Well because you only need to get to the interview, then you got this in the bag! Persevere, be tenacious, stay positive and never give up!

Welcome! The Introduction!

Hello One & ALL!

I have created this blog as a way to connect with other RNs and become a resource of learning for nursing students. I remember when I was a nursing student. I knew nothing about nursing. I wasn’t one of those people who was a 5th generation nurse, no-one in my family was medical, or had even finished college to be completely honest. I needed a place to ask questions, I needed to ask “stupid” questions without being judged. Some of the forums I used for a while, but even there I found there were some of those “eat their young” bullies, so I quit using them.

I hope to make this a place where anyone can ask question or learn. If you are thinking about getting into nursing, are a student, or are a well seasoned nurse we all need your questions and your wisdom.

One thing that I have found so beautiful about nursing is the learning element – you really do learn something new every day! It is such a vast and versatile field that there genuinely is something for everyone. In nursing school there were things which I knew flat out was not for me, but I didn’t let it put me off nursing. Nursing school is just one of those things you have to get through, to get to where you want to be. 

So there is my little introduction. I hope this is the beginning of a wonderful journey. Please tell others about it – the more the merrier! I would love to have guest posts in the future from experienced nurses in specialty areas, as well as giveaways etc. I am looking forward to the future of this blog!

Much love,

JaeJ,RN